Management of congenital uterine abnormalities

Congenital uterine abnormalities are a heterogeneous group of uterine configurations that may adversely affect reproductive potential. Although subtle variations can occur, the more common abnormalities fall into two broad categories of unilateral development or failure of midline fusion. These abnormalities have been well described for over a century although the mechanisms of their unfavourable impact on fertility and clinical management have not been systematically studied until recently. The quality of the literature on this topic has traditionally fallen below the level on which solid evidence-based decisions can be made. Nonetheless, considerable progress has been made in recent times. The understanding of the aetiology of these abnormalities and how they impact reproduction has matured and evolved and this evolution and the growing body of recent studies better define clinical scenarios in which intervention will clearly and positively impact outcome. This article will review four common congenital abnormalities, their impact on reproduction, options for management and the role of assisted reproduction treatment in maximizing reproductive potential. Recommendations are made with consideration of the quality of the literature in an outcome-driven environment.Congenital uterine abnormalities encompass a broad spectrum of anatomic changes with varying impact on reproductive potential. These uterine abnormalities are described in terms of the degree of separation of the uterine cavity from a single cavity into two separate structures. The terms to describe these abnormalities convey this degree of duplication and may be considered in two broad categories. Firstly, two complete uterine structures (bicornuate): there are two completely separate cavities and uteri within the pelvis. The impact on reproductive potential ranges from none to repeated miscarriage and preterm births. Management is controversial and must be carefully selected to match clinical history and ranges from a wait-and-see approach to full abdominal surgery to unify the uteri into a single structure. Secondly, one uterus with normal external configuration but with complete internal division (septate uterus): a single uterus located in the middle of the pelvis with a single cervix and an internal division creating two smaller uterine cavities. The sepate uterus is associated with repeated miscarriage, preterm birth or infertility. Management requires removal of the septum using a small scope placed within the uterus to excise the septum and ‘unify’ the cavity. Outcomes with intervention result in higher live birth rate and reduction in miscarriage and preterm deliveries. Successful management rests with patient selection and matching clinical history to need for intervention plus adequate patient education. The guiding principle is to determine the most effective intervention for the greatest positive impact in the shortest period of time.